What is the approach to a patient presenting for a 3-monthly depo (depot medroxyprogesterone acetate) shot?

Approach to a Patient Presenting for 3-Monthly Depo Shots

Administer the injection if the patient is within 15 weeks of the last injection (up to 2 weeks late), assess satisfaction with the method, evaluate for any new medical conditions that would contraindicate continued use, and monitor weight changes—no routine follow-up visit is required between injections. 1

At Each Injection Visit

Timing Assessment and Administration

• Administer the injection if the patient is on time (13 weeks) or up to 2 weeks late (15 weeks from last injection) without requiring backup contraception 1, 2

• If more than 2 weeks late (>15 weeks from last injection):

  • Administer the injection only if reasonably certain the patient is not pregnant 1
  • Require abstinence or backup contraception for 7 days 1
  • Consider emergency contraception if appropriate 1

• Early injections can be given at any time when necessary (e.g., patient cannot return at routine interval) with no time limits 1, 2

Required Clinical Assessments

Assess patient satisfaction and concerns:

• Evaluate satisfaction with the contraceptive method and any concerns about method use 1
• Ask if the patient wants to discuss side effects or consider changing methods 1

Screen for new contraindications:

• Assess any changes in health status or new medications that would change appropriateness of DMPA based on U.S. Medical Eligibility Criteria (category 3 and 4 conditions) 1
• Key contraindications include history of stroke, myocardial infarction, pulmonary embolism, deep vein thrombosis, and history of meningiomas 3

Monitor weight changes:

• Assess weight and counsel patients concerned about weight changes 1
• Early weight gain (>5% of baseline weight within 6 months) predicts continued excessive weight gain at 12-36 months 1, 2

Counseling Points to Reinforce

Menstrual changes:

• Remind patients that irregular bleeding, spotting, or amenorrhea is expected and generally not harmful 1, 2, 4
• Bleeding patterns typically improve with continued use, with amenorrhea becoming common 2, 4

STI protection:

• Counsel patients to use condoms for STI protection, as DMPA provides no protection against sexually transmitted infections 2

Bone health:

• Reinforce daily calcium and vitamin D intake, regular weight-bearing exercise, and avoidance of smoking and alcohol 2, 4

Formulation Options

Two equivalent formulations are available:

• 150 mg intramuscularly every 13 weeks 2, 4, 5
• 104 mg subcutaneously every 13 weeks 2, 4

Self-administration option:

• The 104 mg subcutaneous formulation can be prescribed for self-administration as an off-label use 1, 2
• Provide instruction on self-injection technique and sharps disposal if offering this option 1

Common Pitfalls to Avoid

• Do not require routine follow-up visits between injections—patients should return only for reinjection or if they have concerns 1

• Do not limit use to 2 years based solely on bone density concerns—the benefits of pregnancy prevention outweigh the risks, and bone mineral density substantially recovers after discontinuation 2, 4

• Do not fail to counsel about menstrual irregularities—pre-injection counseling significantly reduces discontinuation rates 2, 4

• Do not assume amenorrhea is pathologic—it is an expected effect of DMPA and becomes increasingly common with continued use 2